Healthcare Unionization Isn’t the Only Option

Unions have been a hot topic in the media in the last several months. Unionization votes at auto plants and Amazon warehouses; the Dartmouth men’s basketball team receiving regulatory authority to form a union; nurses’ unions on strike against their hospital employers; physicians-in-training (interns and residents) organizing around pay and hours worked; and now, even fully trained physicians getting together to collectively bargain. Just a few weeks ago, several hundred employed physicians at the health system in my local community filed for and received Labor Board permission to form a union.

Historically, we thought of unions as representatives of hourly skilled and unskilled workers — machinists, farm workers, and clerical staff looking for a living wage and health and retirement benefits. We wouldn’t have thought that students at elite universities and “white-collar” professionals, much less physicians destined for the 1%, would be thinking about unionizing.

So, what’s causing famously independent, hyper-achieving doctors to join the push to organize in a union?

A Changing Professional Landscape

Well, for one, about three-quarters of physicians today are employees of either large health systems, multi-specialty groups, or insurance companies. Many of these are for-profit entities, or even venture-capital owned, and are run by business executives with an eye on the bottom line. In the past, more hospitals were public and community-based and owned; their medical staff was made up of private physicians who worked alone or with a few partners, and were self-managed.

The demographic shift of physicians is also a factor. More than half of medical students are now women. Meanwhile, both men and women physicians are placing more emphasis on work-life balance, and even organizations like the American Medical Association recognize the need for better access to family leave.

The economics of being a physician and the overall economics of healthcare have changed. Medical education is much more expensive — the average debt upon medical school graduation is over $200,000 and is much higher for those at private universities (meanwhile, many other countries provide free or heavily subsidized medical school tuition). Not to mention the years of training after medical school, with often shockingly low wages. Newly minted licensed physicians often have a lot of financial ground to make up to match their wage expectations and to manage their debts.

At the same time, the cost of medical practice is up — computerization, technology, insurance, and being able to pay and provide benefits to attract nurses and other staff. Reimbursement is down, too.

Burnout from heavy workloads and the challenges of taking care of increasingly sick patients were already peaking before the COVID pandemic. Then colleagues started getting sick, dying, or retiring. The pipeline for new physicians hasn’t been able to keep up with the numbers leaving practice or cutting back their hours — the continuation of a trend that started decades ago.

So maybe it shouldn’t be surprising that physicians are turning to unions — they’re employees of business entities, with constrained staffs, tight financial targets and margins, corporate bosses, and sick people to empathetically provide care for. Maybe we should be asking why it took so long for them to raise their voices in unison.

But what if, rather than physicians and other healthcare professionals having to fight management with the power of a union, managers could learn to do a better job supervising healthcare staff and keeping them happy and healthy?

Toward a Happier, Healthier Workforce

For physicians and managers alike, the path to a successful healthcare business is the same: know why you’re in healthcare; obtain and practice the skills you need to work in a highly complex, matrixed system; and know what you don’t know so you can form partnerships to fill in the personal and work skills you have not yet honed.

A set of principles is essential — both for physicians and managers. It helps when both parties are aligned. What do you want to accomplish and why? Hopefully you want patients and the people in your community to feel safe, listened to, respected, and as healthy as humanly possible. One of the means to that end is physicians and staff who also feel safe, listened to, respected, and healthy. Staff need to be treated fairly, and managers must understand the road they’re traveling and the burdens they carry daily.

There is risk in physicians thinking they know everything about everything just because they became doctors. Hubris does not work when it comes to patient care, or to union, or personal relationships with management. That attitude leads to a lot of conflicts and failures. Physicians and managers alike need to understand what it means to share responsibility and authority, to trust when warranted, and to be part of teams that emphasize collaboration and shared failures and successes.

There will be negotiation, and that means knowing how to find common ground that benefits more than just the physician or their employer. That also means knowing when to compromise, being aware that a strong ongoing relationship can be more important than scoring points.

Knowing your limits and developing the skills to work effectively with others is a long-term process — and it’s important for physicians and managers both. Management in a health system or medical practice is not dissimilar to what a physician does to take care of a chronically ill patient. You probably won’t cure diabetes, asthma, chronic heart failure, or arthritis in the spine. But you can almost always find some way, in partnership with the patient, to make some things better, to continue to look for new and better ways to do things, to allow them to have a fuller, more meaningful life.

This is what management and leadership can and should do, whether their staff is unionized or not. If it seems your work environment does not respect and further why you’re a physician — to make the lives of others better, and provide you satisfaction along the way — then seek ways to partner, share, learn, and improve with those you work for and with.

Alan Greenglass, MD, is a retired primary care physician and physician manager. He is author of Curing Physician Management: Why Physician Managers Fail.